Healthcare Provider Details

I. General information

NPI: 1164151411
Provider Name (Legal Business Name): ERIC EIERDAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9017 LOGGERS MILL AVE
LAS VEGAS NV
89143-5416
US

IV. Provider business mailing address

9017 LOGGERS MILL AVE
LAS VEGAS NV
89143-5416
US

V. Phone/Fax

Practice location:
  • Phone: 702-286-1181
  • Fax:
Mailing address:
  • Phone: 702-286-1181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberC53066
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: